Form Doh 420-098 - Carbapenem-Resistant Enterobacteriaceae Form - Washington State Department Of Health
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1
2LHJ Use
ID __
_____
________
Outbreak-related
___
____
Reported to DOH
Date ___/___/___
LHJ Cluster#________
_
LHJ Classification
Confirmed
LHJ Cluster
Suspect
Carbapenem-resistant
By:
Lab
Clinical
Name: ________________
_
Epi Link: _________________
Enterobacteriaceae
DOH Outbreak # ____________
County:
Genus and species:____________________________
(Enterobacteriaceae include E. coli, Klebsiella, Enterobacter, Morganella, Proteus, Providencia, Serratia, and Yersinia.)
REPORT SOURCE
LHJ notified
Yes
No
Reporter name ________________________
______
___
LHJ notification date ___/___/___
Investigation start date ___/___/___
Reporter phone ________________________________
Reporter (check all that apply)
Lab
Hospital
HCP
Primary HCP name _____________________________
Public health agency
Other
Primary HCP phone _____________________________
OK to talk to case?
Yes
No
DK
Date of interview ___/___/___
PATIENT INFORMATION
Name (last, first) _________________________________________________
_
___
_
__
Birth date ___/___/___ Age _______
Address __________________________________________________
Homeless
Gender
F
M
Other
Unk
City/State/Zip __________________________________________________________
Ethnicity
Hispanic or Latino
Phone(s)/Email ___________________________________________________
__
____
or
Not Hispanic
Latino
Unk
Alt. contact
Parent/guardian
Spouse
Other
Name: ___________________
Race
Amer Ind/AK Native
Asian
Zip code (school or occupation): _________________ Phone: ___________________
Native HI/other PI
Black/Afr Amer
Occupation/grade _______________________________________________________
White
Other
Unk
Employer/worksite __________________ School/child care name _________
_
_______
CLINICAL INFORMATION
Onset date: ___/___/___
Derived
Diagnosis date: ___/___/___
Illness duration: _____ days
Y= Yes
DN= Don’t know
Infections associated with culture (check all that apply)
Hospitalization
N= No
NA= Not asked
Y
N DK NA
None
Unknown
Abscess, not skin
Hospitalized at least overnight for this illness
AV fistula/graft
Bacteremia
Catheter site
If yes, Hospital name ______________________
Cellulitis/Skin
Decubitus
Empyema
Admit date ___/___/___
Endocarditis
Meningitis
Osteomyelitis
Discharge date ___/___/___
Still hospitalized
Peritonitis
Pneumonia
Pyelonephritis
Admitted to intensive care unit
Septic arthritis/ Bursitis
Sepsis
Skin abscess
Died from illness
Death date ___/___/___
Surgical incision infection
Surgical site infection (internal)
Autopsy Place of death __________________
Disposition
Non-healthcare setting
LTCF
LTACH
Traumatic wound
Urinary tract infection
Another acute care hospital
Unknown
Ulcer/wound, not decubitus
Other:______________________________________________
Other ____________________________________________
Laboratory
Underlying Conditions (check all that apply)
Collection date: ___/___/___
None
Unknown
AIDS/CD4 count < 200
Specimen type:
Blood
CSF
Bone
Pleural fluid
Alcohol abuse
Chronic Liver Dz*
Chronic Lung Dz*
Peritoneal fluid
Pericardial fluid
JointSynovial Fluid
Chronic Renal Dz*
Chronic Skin Breakdown
Urine
Normally sterile internal body site
Other normally sterile site
Wound
Abscess
Sputum
Congestive Heart Failure
Current Smoker
Endotracheal aspirate
BAL
Skin
Rectal swab
CVA/Stroke
Cystic Fibrosis
Decubitus/Pressure Ulcer
Other: _____________________________________________
Dementia
Diabetes
Hemiplegia/Paraplegia
Resistant/Intermediate to
Doripenem
Ertapenem
HIV (not AIDS)
Active Hematologic Malignancy
Imipenem
Meropenem
Immunosuppressive therapy ( past 6 months)
IVDU
rd
Resistant to
3
gen Cephalosporins
Myocardial Infarct
Neurological Problems
Testing for carbapenemases
Peripheral Vascular Dz*
Premature Birth
P N NT DK
P = Positive
N= Negative
Hodge Test
Solid Tumor (metastatic)
Solid Tumor (non metastatic)
NT= Not Tested
DK=Don’t know
KPC pcr
Transplant Recipient
Urinary Tract Abnormality
NDM pcr
Other
___________________________________________________
VIM pcr
IMP pcr
*Dz=Disease
OXA48-like pcr
Answers are: Yes, No, Unknown to case, Not asked/Not answered
DOH 420-098 (Rev. Apr. 2013)
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